Treatment%20protocols%20at%20ECT

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Treatment protocols at ECT

• Dr Grace Fergusson

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Treatment protocols

• past
• present
• future

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development of protocols

• 1939-69 high efficacy
• high side-effects
• 1975-85 low efficacy
• low side-effects
• 1985-00 search for theraputic supremacy

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development of protocols (2)

• 1939 - 69
• sine wave electricity
• little attention to dose
• side-effects accepted or ignored

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development of protocols (3)

• 1969 - 85
• any seizure activity accepted
• re-introduction of pulsed wave forms
• doses of electricity low
• unilateral ECT
• College statement 1977

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development of protocols (4)

• 1985 - 89
• importance of dose intensity
• 25 sec seizure as a guide
• College guidelines 1989

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intensity of electrical dose

• Lambourne Gill 1978 (L G)
• cf.
• Royal Edinburgh DB trial 1979 (RE)
• Northwick Park ECT trial 1980 (NWP)
• Sutton Hospital DB trial 1981 (SH)
• Leicestershire trial 1984 (L)
• see notes

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intensity of electrical dose (2)

• A double blind controlled comparison of the
  theraputic effects of high and low dose energy
  electroconvulsive therapies. Robin and deTissera.
  BJPsych. 1982141
• 1. low dose
• 2. high dose with pulsed energy
• 3. high dose with chopped sine wave
• resultssame seizure length
• 2 and 3 more efficacious 3 more
  side-effects than 2

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development of protocols (5)

• 1989 - 95
• concept of seizure threshold (ST)
• variability in seizure threshold
• change in ST with treatment
• treatment to suit the individual
• College guidelines 1995

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millenium treatment protocols

• bilateral ECT as treatment of choice
• dose 50-100 above seizure threshold (ST)
• measure seizure length as a guide to ST
• restimulate missed seizures, higher dose
• terminate prolonged seizures

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efficacy data for setting dose

• Sackeim et al. (series of studies 1991 - 93,
  USA)
• low dose UECT - 28 response
• low dose BECT - 70 response
• same seizure length
• cognitive side-effects related to dose above
  seizure threshold rather than absolute dose
• conclusion best outcome when the dose exceeds
  seizure (BECT) threshold by 50 - 100 for
  a given individual

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seizure threshold - first ECT

• measure. pros specific
• theraputic, despite seizure length
• decreased risk of overdose
• cons time under anaesthetic
• risks of repeated stimulation?
• estimate. pros quick
• cons variation from the mean in 1 in 20
  so need clinical feedback

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variations in seizure threshold

• raised by incr. age
• male sex
• dehydration
• low oxygen
• propofol
• propranolol
• benzodiaz.
• bilateral electrodes

• lowered by female sex
• low CO 2
• some drugs
• caffeine
• unilateral electrodes

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subsequent treatments (seizure threshold
measured)

• monitor length of seizure
• increase dose if fit length falls by 30-50
• re-titrate after 6th ECT

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subsequent treatments(seizure threshold
estimated)

• take account of clinical picture
• reduce dose if any cognitive side-effects
• increase dose if fit length falls by 30-50
• increase dose if no improvement

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initial seizure threshold
first dose 1997 1999 of ECT (n36) (n35)
measured 22 26 estimated
56 63 fixed 22 11 (Scottish Audit of ECT
1997-00)
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stimulus dosing protocols

• Scotland
• 1994 77
• 1997 89
• 1999 94
• 2000 100
• (E W in 1996 34)

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outcome in a clinical setting

• definite improvement (MADRS/CGI)
• diagnosis 1997 1999
• depressive illness 72 72
• schizophrenic illn. 66 61
• manic illness 65 68

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questions for 2001

• is seizure threshold measurement worthwhile in a
  routine clinical setting?
• is high dose unilateral ECT a better option?
• what can we gain from EEG monitoring?

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choice of electrode placement

• type of ECT outcome side-effects
• 1. low dose UECT 22
• 2. high dose UECT 70 (high relapse) I
• (2.5 x ST)
• 3. low dose BECT 70 II
• 4. high dose BECT 80 III
• Sackeim et al. New Eng J of Medicine, 1993.
  328839-846

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EEG monitoring

• detection of prolonged seizures
• indication of efficacy??

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conclusion

• ECT is a safe and effective treatment
• provided
• care is taken to fit the treatment to the patient